New VA Rule Allows Nurse Practitioners to Stand in for DoctorsU.S. Veterans having sought medical treatment at a Veterans Affairs facility in the past may have experienced especially long wait times. However, on January 14, that inconvenience just might be a thing of the past—that’s when certain registered nurses will be allowed to see patients without a physician present, a change that’s expected to streamline care for veterans.

Earlier this month the VA finalized a rule permitting advanced-practice RNs to practice full medical authority at VA facilities (this rule does not extend to registered nurse anesthetists, however). The finalization comes after a protracted period of consideration at both the VA and in Congress.

Spokespersons for the VA have expressed the belief that the full scope of practice rule for nurse practitioners will boost the number of primary care providers accessible to patients, thereby improving healthcare services overall.

But not everyone sees the rule as a step in the right direction.

Head of AMA expresses concern and dismay over VA final decision

Dr. Andrew Gurman, president of the American Medical Association (AMA), had this to say in a statement:

“This part of the VA’s final rule will rewind the clock to an outdated model of care delivery that is not consistent with the current direction of the healthcare system.”

He also opined that state law should take precedence, rather than a VA rule (nurse practitioners are allowed full scope of practice in roughly 50% of the states).

The AMA’s unhappiness with the VA’s decision is not brand-new. When the rule was still in the proposal phase last spring, Dr. Stephen R. Permut, Board Chair of the AMA, used a written statement to express his disappointment in the “unprecedented proposal to allow advanced practice nurses (APRN) within the VA to practice independently of a physician’s clinical oversight, regardless of individual state law.”

Stressing the “tremendous value” of physicians within the team of professionals treating patients, he said, “All patients deserve access to physician expertise, whether for primary care, chronic health management, anesthesia, or pain medicine.” He added: “We feel this proposal will significantly undermine the delivery of care within the VA.”

View of Association of Nurse Practitioners dramatically counters AMA’s

The American Association of Nurse Practitioners (AANP) is the largest membership organization for nurse practitioners and represents more than 222,000 members. The group applauds the VA’s finalized decision.

From a press release penned by Dr. Cindy Cooke, President of the AANP:

“This final rule is a critical step for America’s veterans to be able to obtain timely, high quality care in the Veterans Health System. We are pleased the VA will move forward with allowing veterans throughout the country to have direct access to nurse practitioner provided health care.

“An unprecedented number of Americans including veterans, their families and caregivers responded to the VA’s request for comments, and we are pleased that their voices were heard.

“America’s nurse practitioners are honored to continue to serve our nation’s veterans by providing them with direct access to the high-quality health care they deserve. We trust that in the near future, the VA will propose a plan to include Certified Registered Nurse Anesthetists (CRNAs) in this provision.”

Nurse Anesthetists excluded from VA’s full scope rule

The VA was convinced not to include nurse anesthetists in the rule…convinced, perhaps, by the American Society of Anesthesiologists (ASA), a group emphatically stating that a physician anesthesiologist should, without exception, be present during surgeries.

The ASA expressed confidence in the number of physician anesthesiologists available to patients, and also expressed the belief that if the rule extended to nurse anesthetists it would result in “lowering the standard of care for our veterans and putting their lives at risk.”

Further, the ASA compared the two practitioners in terms of training and education, noting that physician anesthesiologists receive up to 16,000 hours of clinical training and up to 14 years of education, while nurse anesthetists receive 2,500 hours of training and around half of the education.

The VA’s finalized rule states:

“VHA believes that VA does not have immediate and broad access problems in the area of anesthesia care across the full VA health care system that require full practice authority for all CRNAs.”

VA rule doesn’t necessarily reflect tenor of comments received

During the comment period coming on the heels of the draft rule, the VA gathered over 220,000 comments. More than 100,000 comments were against full authority for CRNAs. Over 45,000 were in favor of full practice authority but failed to specifically refer to CRNAs. And nearly 10,000 comments backed giving practice authority to CRNAs.


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